Our 3 Microgrant Application

Full Legal Name

Date of Birth

Current Physical Address

Email Address

Phone

Number of People in Your Household (Including yourself)

Please list the name, age, and relationship of other members of the household. Enter N/A if not applicable.

Are you a domestic violence survivor?

Are you in need of safety planning assistance?

Yes

No

What is your relationship to the person who is/was harming you?

Spouse

Ex-Boyfriend/Ex-Girlfriend

Live-In Partner

Other

Are you currently employed?

Income Source

Total Monthly Income

What brought you to our organization? Share only what you're comfortable with sharing. We keep this information confidential and won't share with anyone without your permission, unless you are in immediate danger.

What will you be using the micro-grant for?

We work within our community to connect our survivors to services that support them. Please check any services you are interested in learning more about.

Please upload a copy of your photo ID or any document (piece of mail, bill, etc.) that identifies you.

***By signing this application, the applicant certifies that all of the above information and attachments are true and correct to the best of the applicant's knowledge and belief. Applicant agrees that the actual provision of assistance, if approved will be in accordance with the policy of Our 3 Memorial Foundation, Inc.

Signature

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